- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,344.23 / $7,762.47
| Facility | | $2,089.30 | $2,344.23 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,698.24 / $3,548.13
| Professional | | $1,479.11 | $1,698.24 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,290.87 / $2,818.38
| Professional | | $1,202.26 | $2,290.87 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $33.11 / $2,137.96
| Professional | | $32.36 | $33.11 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,187.76 / $3,715.35
| Facility | | $1,621.81 | $2,187.76 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,187.76 / $2,818.38
| Professional | | $1,202.26 | $2,187.76 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $5,128.61 / $19,498.45
| Facility | | $3,090.30 | $5,128.61 | $19,498.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,187.76 / $3,467.37
| Professional | | $1,659.59 | $2,187.76 | $3,467.37 |